Other·August 24, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED STANDARD SURVEY for Entity Reported Incident Number's: CA00522613, CA00502798 and CA00501489 Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #28522 Health Facilities Evaluator Nurse. No deficiencies were identified for Entity Reported Incident: CA00501489 Deficiency Identified for Entity Reported Incident's CA00522613 and CA00502798 at F 323

F323 SS=E FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 08/05/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent altercations for 1 of 4 sampled residents (Resident 1) when Resident 1, who had a history of resident to resident altercations, was punched by Resident 2 five times with a fist to the head in rapid succession. This placed Resident 1 and other residents in the facility at risk for severe injury. Findings: Resident 1's admission facesheet, dated 2/13/17, indicated Resident 1 was admitted to the facility on 4/12/16 with diagnoses that included left side paralysis following a stroke, disorientation, social and emotional deficits following the stroke and major depressive disorder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Social Service Staff noted, on 2/13/17 at 12:39 p.m.: "As the IDT [interdisciplinary] team was doing their morning COC [change of condition] rounds, we were gathered around the South Station when movement down the hall drew attention. [Resident 2] was attempting to come out of a room but another resident [Resident 1] was moving down the hallway and was in front of the door that [Resident 2] was trying to exit. [Resident 2] was seen hitting a resident [Resident 1] in the head with his fist approximately five times in rapid succession..." IDT notes, noted by Social Service Staff, dated 2/14/17 at 10:29 a.m., noted:"...Resident [2] is very proud and independent man who reports being frustrated with the patient [Resident 1] who wanders around saying Help me. Staff monitoring this resident's behavior as well as the other resident [Resident 1] who usually has a 1:1 [one to one observation] with agency attendant. The incident happened at 10:30 a.m. and his [Resident 1's] attendant comes at 11:00 a.m..." Resident 1's Care Plan, date initiated 9/9/16, noted Resident 1 was involved in the following altercations with other residents: On 8/9/16, Resident 1 was tapped by another resident when Resident 1 wandered into another resident's room. On 9/8/16, Resident 1's ear was pinched and pulled and he was hit in the face with a closed fist by another resident. On 2/13/17, Resident 1 was hit on the top of his head by another resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Interventions included: Intervene as necessary, approach/speak to Resident 1 in a calm manner, divert attention, and remove Resident 1 from situation and take to alternate location. On 9/16/16 an intervention was added for one on one care for Resident 1 provided by an outside agency for 30 days during waking hours and re-evaluate. A medical consultation for behavioral issues was conducted on 9/15/16. The physician noted Resident 1 had intermittent altercations with residents due to Resident 1's poor recognition of boundaries, repeated intrusiveness, and loud repetitive phrases. During an observation on 2/22/17 at 10 a.m., Resident 1 was seated in a wheelchair by his bed with no staff visible in the room or hallway. At 10:10 a.m., Certified Nursing Assistant (CNA) A entered the room wheeling another resident into the room following a shower. During a concurrent interview, CNA A stated she was assigned to Resident 1 that shift, along with other residents. CNA A stated when she was busy doing other duties with other residents she would tell the nurse, so they could keep an eye on Resident 1. CNA A stated Resident 1 could be cooperative at times and combative at others. CNA A stated Resident 1 frequently wheeled around the facility yelling, "help" all the time. During an interview, on 2/22/17 at 10:30 a.m., Licensed Nurse (LN) B stated Resident 1 usually slept late and then sat in his wheelchair in the hallway to eat breakfast. LN B stated if Resident 1 was mellow and quiet, Resident 1 would sit in the wheelchair at the nursing station where the nurses watched him. LN B stated if Resident 1 was calm the CNA's would FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE take him to the Activity Room before the (one to one) sitter arrived at 11 a.m. LN B stated that if Resident 1 started to wheel around the facility, nursing staff would ask for extra help from the CNA's. During an observation and concurrent interview, on 2/22/17 at 11:20 a.m., Caretaker C was seated beside Resident 1 in the Activity Room while Resident 1 was sleeping in the wheelchair. Caretaker C stated Resident 1 was very sleepy that day, but usually wheeled constantly around the facility yelling "Help, Help", Caretaker C stated she followed Resident 1 and tried to decrease contact with other residents and keep Resident 1 out of other resident's rooms. During an interview, on 2/2/17 at 1:15 p.m., LN D stated Resident 1 had difficult behaviors. LN D stated one minute Resident 1 would be sleeping and the next minute he would strike out. LN D stated Resident 1 constantly wheeled around the facility hollering "Help me," and when Resident 1 was agitated, all staff were to stop what they were doing and assist in keeping Resident 1 and other residents safe. LN D stated Resident 1 was on "line of sight" (staff maintains visual range of the resident) until the sitter came on duty. During an interview, on 2/22/17 at 3:05 p.m., Social Service Staff E stated another agency provided a sitter / private caregiver for Resident 1 from 11 a.m. until 9 p.m., when Resident 1 was usually awake. When asked why Resident 1 did not have a 1:1 sitter prior to the agency provided sitter's arrival at 11 a.m., Social Service Staff E stated, "it's expensive." Social Service Staff E stated the facility had hoped to adjust Resident 1's medications so Resident 1 would not need one to one observation, but Resident 1's spouse was reluctant to use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications. Social Service E stated she had a conversation with Resident 1's spouse where she explained that Resident 1 was not popular at this facility with the other residents due to the roaming around the facility yelling help and going in and out of other resident's rooms. Social Service Staff E stated the facility had a large community, and other residents were tired of the yelling and Resident 1 going in and out of other resident's rooms and roaming around the facility. Social Service Staff E also stated that even when Resident 1 was on one to one observation Resident 1 would still holler "Help me" and strike without warning. During an interview, on 2/22/17 at 3:35 p.m., Resident 3 stated Resident 1 was his roommate and would go non-stop for 1 or 2 nights and yell, "Help me, help me" and then would be quiet for a day or two. Resident 3 had a physician order, dated renewed on 2/17/17, indicating Resident 3 had the capacity to make all medical decisions. During an interview on 2/22/17 at 3:50 a.m., LN F stated Resident 1 had a history of hollering and thrashing about and had grabbed his arm and it was difficult to get away from Resident 1, who had a very strong grip. LN F stated Resident 1 was unpredictable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1WE11 Facility ID: CA010000066 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055987 (X3) DATE SURVEY COMPLETED 07/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROADWAY VILLA POST ACUTE 1250 Broadway Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: W1WE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA010000066 (X5) COMPLETE DATE If continuation sheet 7 of 7